I was recently in Shanghai, and frequently passed people in shops and on the street wearing surgical masks. In some places they’re worn to filter the polluted air, but they’re also worn throughout Asia in an act of civic duty: to protect others from the wearer’s germs. Every time I saw someone in a mask I’d feel a great rush of gratitude, and wonder if this considerate, communitarian act was rooted in communism, or perhaps Buddhism. In Australia, if you were to back away from a colleague with a cold, or refuse a kiss from a sick friend, you’d more likely than not be considered ill-mannered, if not paranoid. It would have been offensive to point out to the sick doctor, sitting right beside me, bemoaning her terrible symptoms while repeatedly sighing her wet, virus-loaded breaths directly into my face, that her actions were uncharitable. To hand her a mask? Unspeakably rude.
I thought of those masks and all they signify when I heard about the recent outbreaks of measles and chickenpox in affluent areas of Australia and the US. Bloody anti-vaxxers, I thought. Where’s their sense of civic duty? To be fair, it’s not only “neoliberal” parenting (as one commentator pretty accurately deemed it), it’s also about mistrusting authorities. I’m all for that, but these guys are punk rock in the same way as the climate-change deniers. About 5 per cent of the population can opt out of measles immunisation and seek shelter in the dutifully jabbed herd. The figure’s 10 per cent for chickenpox. Any more than that puts us at risk of an outbreak. Given these facts, refusing vaccination is not intellectual bravery; it’s self-entitled. It’s awfully impolite. And the rest of us politely accommodate their stance.
We would not likely be so obliging were we facing outbreaks of viruses whose names still make us tremble: Ebola or Zika. Rejecting measures that protect the greater community from headline horrors wouldn’t be framed as “alternative” or “freedom of choice”. When it comes to public health, the personal is communal. Plato said that to have a “healthy” city, people must act as each other’s partners and helpers. His alternative is a doomed “fevered” city: a place where everyone acts for themselves.
Last weekend a registrar fronted to work with a cough and streaming nose. I suggested he go home. He shrugged. “I’m okay, and there’s no one to replace me.” Malcolm Gladwell writes that politeness can be socially detrimental when the stakes are high. It’s cowardice in disguise. In some situations you simply have to tolerate the discomfort that can come from being rude. I considered my options (we were already a registrar down and the place was crawling with patients), asked the registrar to wait a minute, walked to the storeroom and came back holding a mask. Feeling a stab of guilt, I held out the mask and said, “I appreciate your dedication, but I want you out of here as soon as possible. And while you’re here, you’re wearing this.”
A Bad Case of the Flu
If you work in a public hospital, you know that winter will bring overflowing wards, staff shortages and incessant phone calls from the infection-control unit until you finally front up for your flu shot. The program is designed to protect us from infecting our patients. I’m ashamed to admit it but I avoided getting the vax my intern year. I’d overheard my senior registrar refuse. She backed away from the roaming flu-vax nurse, saying she had a cold and was worried she’d develop Guillain–Barré syndrome were she vaccinated. I was more scared of GBS than of the flu, so I spent that winter dodging the vaxxers.
Had I bothered to actually check the risk of GBS I’d have discovered it to be vanishingly rare, and more often a complication of actual flu. But it’s funny how easily a scary rumour or half-understood belief can overwhelm logic, science and common sense. I once shared an office with a specialist who was a hard-nosed positivist about all medical matters except for his refusal to vaccinate his children or eat food heated in a microwave oven, and his belief that a special pot plant he kept on the filing cabinet was absorbing our computers’ harmful electromagnetic radiation. When it comes to self-protection it seems the human animal is particularly vulnerable to magical thinking.
We had a bad flu season this year. The wards were full of people with Influenza A rasping, “But I had my flu shot!” It wasn’t because this year’s strain was especially virulent. It was primarily because this year’s vaccine didn’t provide good cover for the main strain of Influenza A that ended up in circulation: a type (H3) that’s hard to grow in labs, more inclined to “antigenic drift”, more likely to affect the old and the very young.
Determining which three or four strains to include in each year’s vax is a work of prediction that requires a massive global effort. It’s tricky, because the circulating strains frequently change. The final viral contenders are chosen at the biannual World Health Organization meetings where scientists from all over the world share data collected from what is a continual, worldwide surveillance of circulating influenza strains. The strains to be included in Australia’s 2018 vaccine, for example, were determined in September 2017 – because it takes about six months for licensed pharmaceutical companies to make the vaccine from prediction to syringe.
The influenza vaccine is made inside fertilised chicken eggs. (Hundreds of millions of eggs are used each year.) The eggs are infected with the flu virus, incubated for a few days until (much like crowded trains in winter) they’re fit to burst with virions (virus particles). The fluid inside the eggs is then sucked out, the virus is rendered inactive, then the viral antigen is extracted and put into syringes. When we’re injected, our immune system produces antibodies to the viral antigens so that if we’re hit by that particular strain of flu we can annihilate it before it turns us into a bed-bound wreck. In a normal year there’ll be a 50 per cent success rate, which – all things considered – is pretty good.
I thought all this collaboration was a straight-out good news story when I first heard about it. I imagined a bunch of colleagues huddled in a warm WHO room, sharing notes, predicting influenza patterns, and keeping their eyes on viral strains in ducks and pigs that might leap into humans at a moment’s notice and lead to pandemics. A pandemic (or worldwide outbreak of an infectious disease) occurs when a virus that our immune systems have never encountered starts to circulate. There have been influenza pandemics every few decades for the last 450 years. The Spanish flu of 1918–19 infected a third of the world’s population and killed tens of millions of people.
Protecting the world from catastrophe requires everyone involved to use the kind of social skills taught in kindergarten: cooperation, veracity, a willingness to share. But even kids know that our capacity to act in these ways may be hampered by things like hunger, fear, poverty, or the promise of stacks and stacks of cash.
Globally we have the capacity to produce a few hundred million influenza vaccines each year and a population of 7.5 billion. If there’s a need for a pandemic-preventing vaccine, who gets the protection?
The last time WHO actually declared an influenza pandemic was in response to the 2009 Influenza A (H1N1), or “swine flu”, outbreak. Thankfully, the virus turned out to be far less virulent than was at first feared. However, WHO’s declaration triggered a mass automatic and pre-contracted buy-up of vaccines and antiviral drugs by (the wealthier) governments worldwide, costing many billions of public health dollars. It was later revealed that some of the experts advising WHO received funding from the pharmaceutical companies that benefited from the decision (those who manufactured the vaccines and antiviral treatments). Further, the efficacy of antiviral treatment drugs had been overstated in the drug-company trials and – unlike vaccines – are of uncertain benefit in a pandemic situation. WHO recently removed the main one (oseltamivir, aka Tamiflu) from the list of essential medicines, but not before it generated sales of US$18 billion for Roche (half of which came from government stockpiling).
That profit-seekers will attempt to infect and misdirect the actions of our governments and international organisations is well established. (Think of coal and tobacco, for example.) In matters of global significance, the conflicts of interest that can arise from industry in
filtration, partnerships or “market-based solutions” – whether declared or not – could be disastrous. Vigilance is essential, because when it comes to public health, the belief that big business would voluntarily forsake profit to save us is, like the pretty plant on the filing cabinet, just magical thinking.
Preparations for the Storm
I’m not fond of the heat. I’ve toyed with the idea of moving overseas my entire life. Greenland was my destination of choice as a kid. Then Alaska, Iceland, Hobart. For the past decade it was London. Grey skies and incessant drizzle, or so I’d heard. So when I flew there recently, I packed an umbrella, gloves and a jacket – and arrived during a freak heatwave.
London herself was ill-prepared. Taxi drivers imploded, the hotel’s aircon failed what may have been its first test. People on the streets were a wilting pink mass. At train stations, a kind female electronic voice repeatedly warned us to carry bottled water and urged us to hold off hitting the emergency stop button in the event of distress, explaining that it would be impossible to provide assistance were we trapped in a tunnel a mile beneath London. Even if I wanted to obey her – which I was inclined to, given her politeness and her clear rationales – the platform vending machines stood in belligerent emptiness. Unprepared, all of us. I wondered if kids of the future would sing global-warming nursery rhymes that contained comforting if useless health tips equivalent to the pocket full of posies before we all fall down. I wondered how the already struggling NHS hospitals would accommodate the inevitable deluge of the desiccated and the collapsed.
Most jobs entail periodic work avalanches. I worked for years as a TAB cashier, and the avalanche came a few seconds before the jump. At Myer men’s collections, it was Christmas Eve and then Boxing Day. Waitressing, it was every night, the roomful all thirsty, hungry and needing more bread at exactly the same time. The day before press, the minutes prior to boarding, the sound of the bell at the theatre. Workers sweat to accommodate our last-minute dashes. In hospitals the crush is weather-dependent: heatwaves, and the three months of winter.
I was on the wards for most of this year’s winter, an ultra-marathon of pneumonia, gastro, ODs and flu. And, as in any winter hospital, there was never enough of anything to go round. Not enough beds, not enough staff. It was week after week of Boxing Days. Department stores quadruple their staff to prepare for the Christmas rush, but it’s difficult to flex up a diverse group of highly trained multidisciplinary staff, let alone provide an extra thirty beds in institutions that are funding-strapped and already fit to burst. Management do their best. They fantasise ways to increase efficiency, decrease waste, maximise flow. They devise protocols, “stretch targets” and KPIs. Nothing turns them on quite like a winter squeeze.
Every clinician in a winter-crowded ward is under constant pressure to make room for more patients. They juggle the needs of the individual patient they’ve started to treat with those of the institution and those of the soon-to-be patients mobbing the emergency department corridors. Deciding that a patient is well enough to go home is a negotiation between them and their doctor. There are those who want to take to their own beds as soon as the drip’s out. Those who want to stay till they can run around the block. Doctors vary in their ability to tolerate risk. In the US, they send patients home when they cannot pay. Is it any different to send someone home earlier than you’d like because the hospital needs the bed, or because LOS (length of stay) is a KPI and you’re being watched?
A hospital bed is much like a table in a restaurant. If you can seat and feed and boot out three sets of diners on each table each night, you’ll triple the number of people you serve and generate more income. But there won’t be any chitchat from the waiter. Take away a doctor’s time for chitchat, and you may as well hire technicians to do the job. Like radiologists, we could make the diagnoses from home, based on the data the techs collect. Hey, electronic voices could even deliver prerecorded treatment advice to the patient. (“Play her the pneumonia package, Siri.”)
There are sensible and humane ways to decrease a patient’s LOS: don’t harm your charges, review them regularly, visit them at their home the days after an early discharge, find them somewhere to live. But surely, I still think, there must come a point where you’re doing as much as you can with what you’ve been given. Saying this is not only a waste of breath, it’s considered a whine. We’re asked to pitch in, to find new ways to pare, to – as one manager put it – “prepare for the storm”. He didn’t mean next winter. He meant for a future where there are even more patients and even less funds.
A few weeks ago I found myself in a vast and festive room with a crowd that included the three party leaders: blue, red and green. In my brief and separate conversations with all three, each raised the obesity epidemic. Sugar tax? two wondered. Cash incentives? mused the other. I was a disappointment. I didn’t have a pithy and easily digestible solution to offer regarding this bio-psycho-social-consumer catastrophe. But I imagined being them. These guys don’t prepare for storms; these guys change the weather. As my brother would say, How cool is that?
To change the weather, to prevent the storm – and everybody working in health knows it – would require a gigantic system overhaul: the integration of community and hospital care, robust bio-psycho-social community services, serious and disruptive disease prevention strategies. And, just like halting actual climate change, this is increasingly unimaginable, given our shrinking, split and gutless governments, and the aggressively defended interests of industry. Keep your eye on the forecast. Pack your own water and tarp. In the event of emergency, join the queue.
Society’s Safety Net
All my writer friends say, “You’re so lucky to have a real job, which has a real effect, in the real world.” They say it with an existential sigh. “You actually help people.” I usually just nod, my counterarguments too huge to mount.
I’ve fallen back into my dream of running away, to a place like rural Maine in winter, where you sit inside by a wood fire and watch coyotes dive for mice in the snow. Where you’re living so deep in the woods there is nothing and no one and nowhere else. I want to be snowed in, for a very long time.
I had a friend at university who ran away to join the Carmelites. One minute she was a vegan painter and the next she was in a closed order: cloistered, silent, with all day to read. Though I’m not a believer, it sounded almost as good as the snow.
Then a few years ago I moved house and my new next-door neighbours were nuns. My nuns are not like my friend. They wear normal clothes. They work in women’s refuges and soup kitchens, and support refugees. They organise Centrelink and medical appointments, and comfort those dying alone. They leave early in the morning – I watch them through my study window – and work their guts out till it’s dark.
I met Sister Agnes when the real estate agent first showed me through my house-to-be. When I told Agnes I was a doctor, she gripped my forearms, threw an unshackled laugh into the wind and said, “Thank God.”
On auction day, people crowded the street, as if it were a festival. The sisters sat in their front room, holding hands, praying I’d win.
Their order used to inhabit my house too, and they moved between them through a door in the fence. But then, like endangered birds, they started to die out. The few who remain – Sisters Agnes, Maria and Christina – are all in their eighties. Maybe another doctor will take their place when they die.
One day I bumped into Sister Agnes in the street. She looked as if she might cry. I asked her if everything was okay, thinking of Maria’s joints, Christina’s heart. “They’ve defunded the House of Welcome,” Agnes said. St Mary’s House of Welcome is a meeting place for the homeless, lost and chaotic that’s been operating in the Melbourne suburb of Fitzroy since 1959. The House provides meals, showers, company and assistance for hundreds of people living in the margins, those excluded from or unable to access other services. There are no inclusion criteria, no forms to lodge or automated telephone services to negotiate
. It is the House of Welcome. “Where will they all go?” Agnes said, her hands covering her mouth. I stood there thinking of the snow and closed orders, knowing where they will go: to the hospital.
When you work in a public hospital it takes a great deal of denial, repression, alcohol or convoluted self-justification to remain dispassionate about bad public policy. The hospital is society’s safety net, and it hovers 2 centimetres above the ground. If you have no bed, no shoes to stop your feet from getting all cut up and infected, no food, no medicine, no one to help you get to the toilet, if you want to die and have fallen through the chasms between our community resources, it is the grand old public hospital that will take you in.
I recently looked after a young woman with pneumonia. She was covered in bruises and living in her car. At the last women’s refuge her wallet and most of her clothes were stolen. She was on the years-long urgent-category waitlist for public housing. In between hacking coughs, she said, “I might have to go home.”
I’ve visited one of the nuns’ secret houses for women who have been kicked out – or repeatedly kicked in the face – by their husbands. It’s a light and airy house, full of women and children cooking and singing in a communal kitchen. There’s a garden and an aviary, and it all sits safely behind a huge brick fence and funding that is not government-dependent.
Medicare is unsustainable. Welfare is unsustainable. Education is unsustainable. We hear statements like this all the time. Community services are being slashed like it’s harvest time. Welfare organisations that have grown from the particular needs of specific communities are being closed down, tendered and bound into large private companies who will “deliver services” more efficiently. Apparently, these are the sacrifices “we” have to make for “our” children’s and grandchildren’s futures.
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